LEAWOOD, Kan. — Health care policies that rely on non-physician health professionals to expand access to primary care probably won’t solve the problem because nurse practitioners and physician assistants — like many of their physician counterparts — increasingly choose subspecialty practices, according to research by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.

Graham Center researcher Stephen Petterson and his colleagues reviewed the National Provider Identifier that lists nurse practitioner and physician assistant clinic locations and the physicians working in those locations. Nurse practitioners and physician assistants who practiced without a physician were assumed to be providing primary care. Their results showed that fewer than half of physician assistants and slightly more than half of nurse practitioners were practicing in primary care.

“We know family physicians are all primary care physicians. We currently lack comprehensive national nurse practitioner workforce data and, until recently, we’ve had limited access to physician assistant workforce data,” said Andrew Bazemore, MD, MPH, director of the Robert Graham Center. “However, using National Provider Identifiers and estimates that are based on whether nurse practitioners and physician assistants work in the same location as physicians, we are finding that the trends towards subspecialization we see among physicians are also occurring in the nurse practitioner and physician assistant communities. This finding corroborates recent federal studies of nurse practitioners and those of physician assistant organizations.”

The findings might be seen as contradictory to a report from the American Association of Colleges of Nursing referenced in a July 2013 New England Journal of Medicine Perspectives piece, he added. That article suggested more than 80 percent of nurse practitioner graduates were entering primary care.

“That study differs from ours, however, in that it captured primary care degrees at graduation, not actual practice in a primary care setting,” said Bazemore. “Many nurse practitioners graduate with family, adult or pediatric degrees but then go on to work in subspecialty offices, similar to the preponderance of physicians entering residency in internal medicine or pediatrics at the end of medical school who go on to further training and practice in subspecialties.”

In fact, data from the 2010 report of the National Sample Survey of Registered Nurses showed 62 percent of nurse practitioners worked in subspecialty settings and 36 percent worked in primary care settings.

Physician assistants and nurse practitioners wishing to enter primary care may be facing the same pressures as medical students — including rising debt loads and sizable gaps in potential lifelong earnings — if they choose primary care over specialty practice. Graham Center and Macy Foundation research found similar pressures for physicians in a 2009 report. To better understand these trends, the Physician Assistant Education Association recently provided a grant to the Robert Graham Center to perform a similar study on the impact of student debt and other factors on physician assistants’ career choices. The average total student debt for physician assistants was approximately $100,000 in 2008, according to the PAEA.

A four-year nursing degree can range between $25,000 for an in-state and/or public school to upwards of $100,000 for an out-of-state and/or a private school. Online nurse practitioner programs cost an average of $35,000.

“Some factors that influence physicians to choose subspecialty careers may have similar effects on NPs and PAs, including student debt and income gap disparities,” the researchers wrote.

This study demonstrates the need for comprehensive primary care workforce policies that build the primary care physician workforce as well as the ranks of nurse practitioners and physician assistants, according to Bazemore.

“The future of primary care will depend on teams of providers from various disciplines and educational policies that foster those teams,” he said. “Given what we know of primary care impact on costs, patient health and population health, we risk falling well short of our nation’s health care workforce goals if efforts to increase the production of physicians, nurse practitioners and physician assistants aren’t paired with efforts to further encourage trainees in each discipline toward careers in primary care.”

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Founded in 1947, the AAFP represents 124,900 physicians and medical students nationwide. It is the only medical society devoted solely to primary care.

Family physicians conduct approximately one in five office visits -- that’s 192 million visits annually or 48 percent more than the next most visited medical specialty. Today, family physicians provide more care for America’s underserved and rural populations than any other medical specialty. Family medicine’s cornerstone is an ongoing, personal patient-physician relationship focused on integrated care.